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What is mid-substance Achilles Tendinopathy?

The Achilles tendon (or heel cord) is the largest tendon in the human body. It connects the calf muscles to the heel (calcaneus). Mid-substance Achilles tendinopathy is degeneration / inflammation of the fibres within the main substance of the tendon rather than at it's insertion to the heel. This causes the tendon to become thickened and painful (see pic. below).

Achilles tendinopathy
Achilles - non-insertional tendinopathy surgery: Text

What are the indications for surgery?

In the majority of patients, non-surgical treatment is effective. These include physiotherapy, the use of non-steroidal anti-inflammatory medication and activity modification. Cortisone injections are not recommended for the treatment of these types of problems because they can weaken the tendon and make it easier to rupture. Surgical treatment is indicated if there is failure of several months of nonsurgical treatment.

Achilles - non-insertional tendinopathy surgery: Text

How is the operation done?

You will be admitted on the day of operation. The operation takes about 30 min and is routinely done under a general anaesthetic. Occasionally a spinal anaesthetic may be considered. Most patients go home the same day. 

An incision is made over the side of the tendon. The lining and the degenerate core of the tendon (up to 50% of tendon width) are removed. The tendon is then repaired. A segment of the adjacent plantaris tendon is also removed as it can cause irritation. (If however, your tendon is significantly diseased and more than 50% of your tendon needs to be removed, a FHL tendon transfer augmentation may have to be considered. This will be discussed prior to your surgery).

The wound is closed with dissolvable stitches. Your ankle will be protected in a plaster cast or boot.

You will be touch weight-bearing for the first 2 weeks. Once the wound has healed, you can start fully weight bearing in the boot. The boot is kept on for a total of 4 to 6 weeks to allow for the tendon to fully heal.  

Achilles - non-insertional tendinopathy surgery: Text

Aftercare and FAQs

It is important to keep the leg elevated as much as possible especially for the first 2 weeks. You will usually be able to go home when you feel ready. You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours. Your first clinic follow-up is usually 12 to 14 days after surgery.

Wound care – The dressing should be kept dry. At yours first clinic appointment, wound inspection and suture removal will be undertaken.

Work - If you have a sedentary job you should be able to return to work within 2 weeks (if you can arrange safe transport). If your job is physical, you may need to stay off work until the boot is removed.

Driving - You will not be able to drive for 6 weeks following surgery. However, if you drive an Automatic and it was your LEFT side that was operated on; then you may start short drives 2 weeks following surgery. It is advisable to check the terms of your car insurance to ensure your cover is valid, as some policies state that you must not drive for a specific time period after an operation.

Flying after surgery - It is generally recommended to wait at least four to six weeks to fly after any lower limb surgery. It may be possible to fly on short-haul or domestic flights at an earlier time, but you should always check with your GP or surgeon. Always consult your doctor, your health insurance provider and the airline you are flying with before making your flight reservation.

Achilles - non-insertional tendinopathy surgery: Text

What are the surgical risks?


  • Infection

  • Nerve damage – causing numbness and painful scar

  • Deep vein thrombosis (DVT) and pulmonary embolism (PE) – blood clots in the vein or lungs – to reduce this risk you may be prescribed heparin injections for 2 weeks (unless contraindicated)

  • Tendon rupture

  • Residual pain

It is beyond the scope of this document to list rarer risks (less than one in a thousand) but I will be very happy to discuss any worries about specific concerns and also about any family history or your past health problems. If there is anything you do not understand or if you have any questions or concerns, please feel free to discuss them with me.

Achilles - non-insertional tendinopathy surgery: Text
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